NCLEX - W5 - Documentation & Informatics Flashcards
A nurse is caring for a patient who is being discharged from the hospital. Which of the following information should the nurse include in the discharge summary?
a. Patient’s vital signs upon admission
b. Patient’s dietary preferences
c. Instructions for wound care
d. Results of all laboratory tests conducted during hospitalization
Answer: c
Rationale: A discharge summary should include information about the patient’s current health status, any unresolved problems, instructions for care at home (including wound care), and contact information for follow-up appointments.
Which of the following is a benefit of using standardized nursing languages in documentation?
a. Decreases the time nurses spend documenting
b. Reduces the risk of medical errors
c. Enables researchers to retrieve nursing data for aggregation and analysis
d. Simplifies communication with patients and families
Answer: c
Rationale: Standardized nursing languages help make nursing care visible, support nursing research, and allow for interoperability of EHR systems by providing consistent terminology
A nurse is preparing to give a handoff report to the oncoming nurse. Which of the following information should the nurse include in the report?
a. The patient’s favorite television shows
b. The patient’s response to pain medication
c. The nurse’s opinion of the patient’s family
d. The patient’s insurance information
Answer: b
Rationale: A handoff report should focus on client-centered information necessary to maintain continuity of care, such as the patient’s status, recent changes in condition, planned activities, and responses to treatment.
A nurse is documenting care using the PIE format. Which of the following elements should the nurse include in the documentation?
(Select all that apply.)
a. Problem
b. Intervention
c. Evaluation
d. Subjective data
e. Objective data
Answer: a, b, c
Rationale: PIE charting focuses on the client’s problems and includes documentation of the problem, interventions implemented to address the problem, and the client’s evaluation or response to the interventions.
A nurse receives a telephone prescription from a provider. What is the most important action for the nurse to take to ensure accuracy of the prescription?
a. Write the prescription down on a piece of paper.
b. Ask the provider to repeat the prescription.
c. Read back the prescription to the provider for verification.
d. Enter the prescription into the electronic health record immediately.
Answer: c
Rationale: The nurse should “read back” the information to the provider to validate accuracy before taking any action to reduce the risk of errors when receiving telephone or verbal prescriptions.
A nurse is caring for a patient who has fallen out of bed. Which of the following actions should the nurse take?
(Select all that apply.)
a. Assess the patient for injuries.
b. Notify the provider of the fall.
c. Complete an occurrence report.
d. Document the fall in the patient’s medical record.
e. Discuss the fall with the patient’s family.
Answer: a, b, c, d
Rationale: Patient falls require assessment, provider notification, documentation in the medical record, and completion of an occurrence report (which is not part of the patient’s medical record) for quality improvement purposes. Discussing the fall with the patient’s family may be appropriate, depending on the situation and the patient’s wishes, but is not a mandatory action.
Which of the following abbreviations should a nurse avoid using in documentation, according to The Joint Commission’s “Do Not Use” list?
(Select all that apply.)
a. QD
b. IU
c. mL
d. MS
e. mcg
Answer: a, b, d
Rationale: The Joint Commission’s “Do Not Use” list includes abbreviations like QD (daily), IU (international unit), and MS (morphine sulfate or magnesium sulfate) to prevent potential medication errors. Abbreviations like mL (milliliters) and mcg (micrograms) are acceptable to use.
Which documentation format organizes client data according to the client’s problems, eliminating the need for a separate care plan?
a. Narrative format
b. SOAP/SOAPIE/SOAP(IER)
c. Focus Charting
d. PIE
Answer: d
Rationale: The PIE charting format stands for Problem, Intervention, Evaluation. It is organized based on the client’s problems, eliminating the need for a separate care plan.
Which of the following is an advantage of using electronic health records (EHRs)?
a. EHRs eliminate the need for nurses to document.
b. EHRs can be accessed by multiple providers simultaneously.
c. EHRs are less expensive to maintain than paper records.
d. EHRs are immune to security breaches.
Answer: b
Rationale: EHRs offer numerous advantages, such as enabling simultaneous access for multiple providers, improved communication, reduced redundancy, and enhanced data analysis capabilities.
A nurse is documenting care using the SOAP format. Under which section should the nurse document the patient’s statement, “My pain is a 7 out of 10”?
a. Subjective data
b. Objective data
c. Assessment
d. Plan
Answer: a
Rationale: The patient’s pain rating is subjective data, based on their personal experience and perception.
What is a key difference between a handoff report and a transfer report?
a. A handoff report is given between nurses, while a transfer report is given between providers.
b. A handoff report is given at the end of a shift, while a transfer report is given when a patient moves to a different unit or facility.
c. A handoff report is given verbally, while a transfer report is always written.
d. A handoff report focuses on patient problems, while a transfer report focuses on nursing interventions.
.
Answer: b
Rationale: A handoff report is used to transfer responsibility for patient care between nurses at shift change. A transfer report is used to communicate patient information when the patient is moved to a new location, whether within the same facility or to a different facility
Which of the following is a true statement about occurrence reports?
a. Occurrence reports are part of the patient’s medical record.
b. Occurrence reports should be completed for all patient complaints.
c. Occurrence reports should be used to blame staff members for errors.
d. Occurrence reports should be used to identify potential risks and improve patient safety.
Answer: d
Rationale: Occurrence reports are not part of the patient’s medical record. They are used to document events outside the normal scope of care, such as falls, medication errors, or equipment malfunctions, to identify trends and improve safety practices.
A nurse is preparing to document patient care. Which of the following actions should the nurse take to ensure confidentiality of the patient’s health information?
(Select all that apply.)
a. Share computer passwords with colleagues for easy access.
b. Log off the computer system when not actively documenting.
c. Dispose of printed patient information in designated shred bins.
d. Discuss patient information only with authorized personnel.
e. Leave patient charts open on the nurses’ station for easy access.
Answer: b, c, d
Rationale: Protecting patient confidentiality includes logging off computers when finished, disposing of printed information properly, and only discussing information with authorized personnel. Sharing passwords and leaving charts open compromises confidentiality.
Which of the following are principles of documentation for nursing care?
a. Subjective, vague, and incomplete
b. Accurate, relevant, and organized
c. Delayed, judgmental, and biased
d. Repetitive, redundant, and illegible
Answer: b
Rationale: High-quality documentation must be accurate, relevant, clear, concise, and complete.
A patient’s health record serves which of the following purposes?
(Select all that apply.)
a. Communication tool between members of the healthcare team
b. Diary for the nurse to express personal opinions about the patient
c. Legal record of care provided
d. Source of research data
e. Justification for financial billing and reimbursement
Answer: a, c, d, e
Rationale: The patient record serves multiple purposes, including communication, legal documentation, research data, and financial justification. It should not be used for personal opinions or judgments about the patient.
